Knee Surg Sports Traumatol Arthrosc
DOI 10.1007/s00167-013-2699-1
KNEE
Psychological predictors of anterior cruciate ligament
reconstruction outcomes: a systematic review
Joshua S. Everhart • Thomas M. Best •
David C. Flanigan
Received: 5 April 2013 / Accepted: 27 September 2013
Ó Springer-Verlag Berlin Heidelberg 2013
Abstract
Purpose Lack of return to sport following anterior cru-
ciate ligament (ACL) reconstruction often occurs despite
adequate restoration of knee function, and there is growing
evidence that psychological difference among patients may
play an important role in this discrepancy. The purpose of
this review is to identify baseline psychological factors that
are predictive of clinically relevant ACL reconstruction
outcomes, including return to sport, rehab compliance,
knee pain, and knee function.
Methods A systematic search was performed in PubMed,
Google Scholar, CINAHL, UptoDate, Cochrane Reviews,
and SportDiscus, which identified 1,633 studies for
potential inclusion. Inclusion criteria included (1) pro-
spective design, (2) participants underwent ACL recon-
struction, (3) psychological traits assessed at baseline, and
(4) outcome measures such as return to sport, rehabilitation
compliance, and knee symptoms assessed. Methodological
quality was evaluated with a modified Coleman score with
several item-specific revisions to improve relevance to
injury risk assessment studies in sports medicine.
J. S. Everhart
D. C. Flanigan (&)
Department of Orthopaedics, The Ohio State University Wexner
Medical Center, Suite 3100 Morehouse Medical Plaza 2050
Kenny Road, Columbus, OH 43221, USA
e-mail: david.flanigan@osumc.edu
T. M. Best
Department of Family Medicine, The Ohio State University
Wexner Medical Center, Columbus, OH, USA
T. M. Best
D. C. Flanigan
OSU Sports Medicine, Sports Health and Performance Institute,
The Ohio State University Wexner Medical Center, Columbus,
OH, USA
Results Eight prospective studies were included (modi-
fied Coleman score 63 ± 4.9/90, range 55–72). Average
study size was 83 ± 42 patients with median 9-month
follow-up (range 3–60 months). Measures of self-efficacy,
self-motivation, and optimism were predictive of rehabili-
tation compliance, return to sport, and self-rated knee
symptoms. Pre-operative stress was negatively predictive,
and measures of social support were positively predictive
of knee symptoms and rehabilitation compliance. Kine-
siophobia and pain catastrophizing at the first rehabilitation
appointment did not predict knee symptoms throughout the
early rehabilitation phase (n.s.).
Conclusions Patient psychological factors are predictive
of ACL reconstruction outcomes. Self-confidence, opti-
mism, and self-motivation are predictive of outcomes,
which is consistent with the theory of self-efficacy. Stress,
social support, and athletic self-identity are predictive of
outcomes, which is consistent with the global relationship
between stress, health, and the buffering hypothesis of
social support.
Level of evidence Systematic review of prospective
prognostic studies, Level II.
Keywords Sports
Knee surgery
Psychology

Sports medicine outcomes
Risk assessment
Introduction
Sports-related knee surgery is a common procedure in the
USA, with approximately 130,000 anterior cruciate liga-
ment (ACL) reconstructions and 500,000 meniscus-related
procedures performed annually [30]. In the elective knee
surgery setting, an essential component of the initial
evaluation is an assessment of potential benefit and risk of
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surgery versus the time and cost burden of operative

treatment and knee rehabilitation. Selection of an appro-
priate treatment strategy requires a thorough assessment of
patient lifestyle and treatment expectations, along with
consideration of factors such as pre-injury activity level,
desire to return to sport, occupational demands, willingness
to complete postoperative rehabilitation, and expectations
regarding postoperative knee function [16].
Despite this, variable sports-related outcomes continue
to be reported in selected patient populations [3, 4, 16].
Even after primary ACL reconstruction in an athletic
population with high rates of rehabilitation compliance, a
disappointing rate of return to previous level of sport par-
ticipation ranging between 47 and 70 % is reported at
greater than 4-year follow-up [3–5, 16, 39]. In many cases,
this lack of return to sport occurs without significant
functional deficits in knee stability and strength and with-
out persistent pain [3, 4, 16, 34, 39, 41]. Another factor to
consider is that return to sport after ACLR may not be in
the patient’s best interest if he or she is primarily interested
in avoiding additional injury, as primary ACLR patients are
at increased risk of injury to both the ipsilateral and con-
tralateral limb [9, 59].
Psychological differences between patients may be an
important contributing factor to this apparent mismatch
between postoperative knee function scores (successful
physiological outcomes) and rates of return to sport or pre- Fig. 1 Conceptual diagrams of the fear-avoidance model of pain (a),
injury activity levels (successful participation-related out- the theory of self-efficacy (b), and stress, health, and the buffering
comes) [4, 5]. Differences in psychological and behav- hypothesis of social support (c) in the context of ACL reconstruction
ioural responses to pain are some of the most well-studied
factors that may contribute to a lack of return to sport [2, 4, strongly associated with higher rates of task completion in
5]. Due to the trauma of acute injury, discomfort during rehabilitation [1, 48] and exercise adherence [18]. Finally,
knee rehabilitation, and residual knee symptoms, some stress, health, and the buffering hypothesis of social sup-
patients may fall into a pattern of behaviours similar to port were developed by Cohen [12, 13]. In this model,
what is observed in patients with chronic pain syndromes psychological stress is believed to globally affect physical
[2, 10, 31]. and mental health [63], and an individual’s degree of social
Three basic psychological theories are tested in the support is believed to modulate this effect [13, 57]. One’s
studies included in this review. We have presented these perceived level of social support can be derived from a
theoretical frameworks in the context of ACL injury, variety of relationships; of particular importance in sports
reconstruction, and rehabilitation in a series of conceptual medicine are athletic self-identity and the team environ-
diagrams (Fig. 1). The fear-avoidance model of pain is a ment as a source of social support [24, 62], which can be
cognitive-behavioural theory originally developed by Le- negatively impacted by injury [62].
them et al. [37]; this model has persisted for several dec- Ardern et al. [4] recently demonstrate a consistent
ades and has been extensively validated [35]. In this model, association between psychological factors and returning to
when patients experience a recurrent painful stimulus, an sport after ACL injury. However, their review focuses on
exaggerated negative psychological response to pain or the cross-sectional analyses, and they comment that prognostic
anticipation of pain (pain catastrophizing) [50] leads to an studies are necessary to facilitate inferences regarding
active avoidance of movement out of fear of recurrent pain causation. The purpose of this systematic review is to
or injury (kinesiophobia) [51]. The theory of self-efficacy address this gap in knowledge by identifying psychological
was originally proposed by Bandura [6]. In this theory, traits that have been demonstrated in a prospective manner
individuals have intrinsic levels of self-efficacy, optimism, to increase risk of an unsatisfactory outcome after ACL
and self-motivation, which are considered to be stable reconstruction. Specifically, this review is designed to
personality traits (unchanging from year to year) and are identify baseline psychological traits in patients

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Knee Surg Sports Traumatol Arthrosc
Fig. 2 Study flowchart
undergoing ACL reconstruction that are predictive of
clinically relevant outcomes, including return to sport, knee
rehabilitation compliance, and postoperative knee pain and
function.
Materials and methods
Initial search and primary screening
The guidelines outlined in the PRISMA statement for
standardized reporting of systematic reviews were adhered
to in the preparation of this manuscript [38]. A search was
performed on the PubMed database (1975 to June, 2012)
with the Medical Subject Headings (MeSH) advanced
search tool (Fig. 2). Systematic searches were also per-
formed in CINAHL, UptoDate, Google Scholar, Cochrane
Reviews, and SportDiscus in addition to hand searching of
reference lists of key publications. The titles and abstracts
of the studies identified in the initial screen were then
individually reviewed for the following selection criteria:
1. Studies investigating ACL reconstruction outcomes.
2. Study population consists primarily of physically
active individuals of any experience level with a mean
age 13–65 years.
3. Prospective study design.
4. Predictive assessment of psychological factors as an
injury risk factor was either a primary or secondary
aim of the study.
5. Study is reported in manuscript form in a peer-
reviewed publication. Meeting abstracts, posters, and
thesis papers were excluded.
6. Study reports original research in English.
Nineteen studies met inclusion criteria. The design and
methodology of which were reviewed to determine whe-
ther their analysis and findings were directly applicable to
the objective of this review. Eight studies were excluded
because of their focus on cross-sectional comparisons
between psychological factors and outcome measures [10,
19, 32, 36, 44–46, 56]. Two prospective studies were
rejected because they included psychological testing as part
of their outcome measures but not their baseline measures
[28, 40]. Finally, one prospective study was excluded
because it consisted of a mixed surgical and non-surgical
population [26], resulting in a final total of nine studies
included in this review.
Assessment and risk of bias
In order to assess the quality of the nine selected studies,
the study authors used a modified Coleman score; the
original Coleman score was utilized as an orthopaedic
quality assessment tool for patellar tendinopathy outcomes
studies [14]. Modifications of several items in part A of the
original Coleman score were made in either content or
language to improve their relevance to injury risk assess-
ment studies in sports medicine. Item 3 was changed from
‘‘number of different surgical procedures’’ to ‘‘number of
different screening tests’’ included in each reported out-
come. Item 6 was changed from ‘‘description of surgical
procedure’’ to ‘‘description of clinical screening test’’. Item
7 of the original Coleman score was removed, the content
of which originally pertained to sufficient description of the
study rehabilitation protocol.
Theoretical frameworks and grouping of psychological
scales
As is the case in sports medicine, there are often multiple
clinical scales available to behavioural psychologists to
measure the same general factor; therefore, to facilitate
interpretation, we have grouped the individual scales used
by the included studies according to the psychological
theory being tested (Table 1).
Data collection and reporting
The surgical procedure, patient demographics, sample size,
length of follow-up, pre-operative measures, and outcome
measures for all included studies were systematically iden-
tified and recorded (Table 2). The description of study
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Table 1 Study scale definitions

Underlying theory Category Acronym Scale name Factor assessed

Fear-avoidance model of pain
[37]
Theory of self-efficacy [6]
Stress, health, and the
buffering hypothesis of
social support [13]
Fear-avoidance response
to injury
Optimism and self-
efficacy
Self-motivation
Stress and social support
in the context of athletic
injury
PCS [50] Pain Catastrophizing Emotional response to pain
Scale
TSK-11 [61] Tampa Scale for Fear of activity and re-injury
Kinesiophobia
SIS[29] Sports Injury Survey Self-reported use of positive coping
skills during rehabilitation
SSP [25] Swedish universities Survey of personality traits
Scales of Personality including optimism & pessimism
(embitterment)
SER [58] Modified Self-Efficacy for Perceived ability to perform tasks
Rehabilitation Outcome during injury rehabilitation
Scale
K-SES[53] Knee Self-Efficacy Scale Perceived ability to perform knee-
related tasks
ACL-RSI [60] ACL-Return to Sport after Perceived ability and motivation to
Injury scale return to sport
SMI [21] Self-motivation inventory Self-motivation to complete a task
Psychovitality Psychovitality Scale Motivation and perceived
[23] likelihood to return to sport after
injury
BSI [17] Brief Symptom Inventory Psychological distress
ERAIQ [49] Emotional Responses of Emotional impact of injury and
Athletes to Injury perceived social support
Questionnaire
SSI Social support inventory Overall perceived social support
AIMS Athletic Identity Athletic self-identity (a source of
Measurement scale social support among athletes)

findings was limited to pre-operative psychological factors
and their predictive assessment of knee-related outcomes.
Effect sizes of the identified psychological risk factors were
reported as available from the study manuscript. We did not
perform any secondary calculations with the reported data
with the exception of Gobbi et al.’s [23] descriptive data for
the psychovitality scale; in this case, the authors used an
appropriate nonparametric test (Mann–Whitney U) but
reported inappropriate descriptive statistics (means instead
of medians with interquartile ranges) for these non-normally
distributed data. Finally, though the psychological scales
presented in this paper apply to one of three theories (Fig. 2),
there are insufficient validation studies in the current litera-
ture between scales in a given category to provide a mean-
ingful pooled estimate or perform a meta-analysis.
Results
Study characteristics
A total of eight prospective cohort studies were included
for review based on our screening methodology and
inclusion criteria (Table 2). All studies included both sexes
and did not differentiate between levels of sports compe-
tition in their analyses. Mean ages ranged from 22 to
32 years [11, 52]. Sample size ranged from 38 to 100
(mean 71 ± 22 patients) [23, 54] and duration of follow-up
ranged from 3 to 60 months [11, 52].
Quality assessment with modified Coleman score
None of the studies fulfilled all of the criteria in the modified
Coleman score (Table 3). The mean modified Coleman
score 63 ± 5 out of 90, with a range of 55–72. The studies
achieved a mean score of 41 ± 3 out of 50 points on part A,
which primarily evaluates baseline study characteristics. The
studies scored worse on part B (mean 22 ± 3 points out of
40), which primarily evaluates outcome criteria and
recruitment rates. Of the individual factors on the modified
Coleman score, item 2 had the lowest number of studies that
met the specified criteria (2/8 studies), which required a
mean follow-up of at least 2 years.
Fear-avoidance model of pain
There were negative findings regarding the psychological
response to pain or fear of re-injury and knee surgery

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 Table 2 Included studies
Author Timing of Study participants Baseline measures Outcome measures Study results Modified
assessments Coleman
Psychological scales defined in Table 2 score

Brewer et al. [8] Pre-operative N = 95, 67 male, 28 female, mean Self-motivation (SMI), athletic Rehabilitation effort (sport injury After adjusting for age, self- 63
baseline and age 26.9 ± 8.2 years 53 % identity (AIMS), social support rehabilitation adherence scale- motivation (SMI) was associated
6-month competitive, 43 % recreational (SSI), stress (BSI) SIRAS), compliance (attendance, with rehabilitation effort
follow-up athletes. 90 % of ACL injuries home exercise, & cryotherapy (r = 0.26, p \ 0.05) and home
assessments occurred during sport completion), knee AP laxity (KT exercise completion (r = 0.48,
arthrometer), 1 leg hop distance p \ 0.001), social support (SSI)
(hop index score), activity levels was associated with home
Knee Surg Sports Traumatol Arthrosc

(Tegner activity score) exercise completion (r = 0.22,

p \ 0.05), athletic identity was
associated with knee laxity
(r = 0.38, p \ 0.001), hop index
score (r = 0.26, p \ 0.05), and
knee symptoms (Lysholm score)
(r = 0.27, p \ 0.05), and stress
(BSI) was associated with knee
laxity (r = -0.52, p \ 0.001)
Brewer et al. [7] Pre-operative N = 61, 21 female, 40 male, mean Self-motivation (SMI), athletic Rehabilitation effort (SIRAS) and Age modulated the relationship 60
baseline and age 26 ± 8 years (range 14–47). identity (AIMS), social support compliance (attendance, home between psychological factors
6-month 57 % competitive 41 % (SSI), stress (BSI) exercise, & cryotherapy and knee outcomes. The sample
follow-up recreational athletes, 90 % of completion) was stratified into three age
assessments injuries occurred during sport groups (mean age 18, mean age
24, and mean age 30), and the
slope of the linear regression
changed by strata. As mean age
increased, the relationship (slope)
between exercise completion
(dependent variable) and 1)
athletic identity became more
negative (standardized
coefficient beta = -0.48,
p \ 0.001), 2) self-motivation
became more positive
(beta = 0.31, p = \0.05), and 3)
social support became more
positive (beta = 0.25, p \ 0.05)

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 Table 2 continued
Author Timing of Study participants Baseline measures Outcome measures Study results Modified
assessments Coleman

123
Psychological scales defined in Table 2 score

Chmielewski Postoperative N = 77, 41 male, 36 female, mean Knee symptoms (international knee Knee symptoms (NRS, IKDC) Kinesiophobia (TSK-11) and self- 55
et al. [11] baseline (1st age 22.4 ± 7.1 years, 70/77 documentation committee efficacy (SER) at the first
rehabilitation injured during sport subjection knee evaluation form- rehabilitation appointment
appointment) IKDC, and numeric rating scale (baseline) did not predict
and 3-month for pain-NRS), kinesiophobia 12 week postoperative pain
follow-up (TSK-11), pain catastrophizing (NRS) or knee function scores
assessments (PCS), self-efficacy (SER) (IKDS) after adjustment for age,
sex, and baseline knee pain
(NRS) with hierarchical
regression modelling (p [ 0.05)
Gobbi and Pre-operative N = 100, 67 male, 33 female mean Knee symptoms (IKDC and Knee isokinetic strength, knee Psychovitality scores significantly 72
Francisco [23] baseline and age 28 years (range 17–50), both SANE), activity levels (Tegner motion analysis, return to sport differed between patients who
12-month competitive and recreational and Marx activity scales), and returned to sport (n = 24
follow-up athletes motivation to return to sport patients) at 12 months (median
assessments (psychovitality) 16 points IQR 14–18) and non-
returners (n = 24 patients)
(median 9 points IQR 8–15)
(p \ 0.001, Mann–Whitney U)
Langford et al. Postoperative N = 87, 55 male, 32 female, mean Distress due to athletic injury Knee isokinetic strength, laxity, ACL-RSI at 6 months was 63
[33] baseline (at age 27.5 ± 5.7 years, all (ERAIQ), motivation to return to Lachman/pivot shift test, range significantly higher in athletes
3-month) and participants played sports on sport (ACL-RSI) of motion, presence of effusion, who returned to sport at
12-month weekly basis prior to injury single hop/cross-over hop 12 months (mean 63.2 ± 17.2)
follow-up performance than non-returners (mean
assessments 51.8 ± 16.8) (p = 0.005). A
trend towards significance was
observed for differences in
ERAIQ scores between returners
and non-returners after
adjustment for assessment time
point (p = 0.08, two-factor
repeated-measures ANOVA).
ERAIQ scores did not
significantly differ between
returners and non-returners
(p = 0.08); no adjustment was
necessary for age, graft-time,
time between injury and surgery,
or activity levels as all were non-
significant covariates (p [ 0.05)
Knee Surg Sports Traumatol Arthrosc
 Table 2 continued
Author Timing of Study participants Baseline measures Outcome measures Study results Modified
assessments Coleman
Psychological scales defined in Table 2 score

Scherzer Postoperative N = 54, 17 female, 37 male, mean Positive coping skills during Rehabilitation effort (SIRAS) and After adjustment for covariates 64
et al. [47] baseline (1st age 28 ± 8 years 52 % rehabilitation (SIS) compliance (attendance, home with multiple regression analysis,
rehabilitation competitive and 46 % recreational exercise and cryotherapy use of goal setting as a positive
appointment) athletes completion) coping strategy was predictive of
and 6 month home exercise completion
follow-up (beta = 0.35, p \ 0.05) in
assessments addition to rehabilitation effort
Knee Surg Sports Traumatol Arthrosc

(SIRAS) (beta = 0.51,

p \ 0.005). Use of positive self-
talk as a coping strategy was
correlated with home exercise
completion (r = 0.52, p \ 0.05)
in unadjusted correlation analysis
Swirtun and Pre-operative N = 57 at baseline, 46 at follow-up, Personality traits (SSP) and activity Knee symptoms (knee injury and Low pessimism scores were 67
Renström baseline and mean age 32 ± 7.9 years. 22/46 levels (Tegner) osteoarthritis outcome score- associated with higher KOOS
[52] 60-month patients underwent ALCR (average KOOS) and activity levels scores (Spearman’s rho = -
follow-up 9 months after date of injury), (Tegner) 0.36, p \ 0.05). No adjustment
assessments 24/46 patients had ACLR, 24/46 for age or pre-injury activity
non-operative management levels was performed as both
measures had non-significant
correlations with outcomes
(p [ 0.05)
Thomeé [55] Pre-op baseline, N = 38, 13 female, 25 male, mean Activity levels (Tegner), and self- Activity levels (Tegner and Perceived self-efficacy at 59
12-month age 29.7 years (range 16–55) efficacy (K-SES) physical activity scale-PAS) knee completing knee-related tasks in
follow-up symptoms (KOOS and Lysholm the future (K-SES-future) was
knee symptom score), and one predictive of an acceptable
leg hop (hop index score) outcome according to KOOS
score (sports-recreation OR 1.6,
p = 0.002; quality of life OR 1.5,
p = 0.037), Tegner score (OR
1.7, p = 0.003), or hop index
score (OR 2.2, p = 0.04).
Patients were classified as having
an ‘‘acceptable outcome’’ if they
had a postoperative decrease in
Tegner activity score (compared
to pre-injury levels) of B2, a
postoperative KOOS-sports/
recreation or KOOS-quality of
life subscore of [76 or a hop
index score of [90 %

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Table 3 Modified Coleman scores

Study Part A Part B Total
score
1 2 3 4 5 6 Total 7 8 9 Total

Brewer et al. [8] 10 0 7 15 5 5 42 12 4 5 21 63

Brewer et al. [7] 10 0 7 15 5 5 42 12 6 0 18 60
Chmielewski et al. [11] 10 0 0 15 5 5 35 12 8 0 20 55
Gobbi and Francisco 10 5 7 15 5 3 45 4 11 12 27 72
[23]
Langford et al. [33] 10 0 7 15 5 3 40 0 8 15 23 63
Scherzer et al. [47] 10 0 0 15 5 5 39 7 8 10 25 64
Swirtun and 7 0 7 15 5 5 44 12 8 5 23 67
Renström [52]
Thomeé et al. [54] 7 5 7 15 5 5 39 7 11 5 20 59
Average score 40 ± 3.6 22 ± 2.9 63 ± 4.9

outcomes in the included studies (Table 2). In particular,
Chmielewski et al. [11] reported no association between
kinesiophobia (TSK-11) and pain catastrophizing (PCS) at
the first rehabilitation appointment and knee symptoms at
12 weeks postsurgery after adjustment for age, sex, and
baseline knee pain (NRS) with hierarchical regression
modelling (n.s.); however, interpretations of this negative
finding are limited by the study timeframe, which only
includes the early postoperative rehabilitation phase.
Theory of self-efficacy
A significant relationship was demonstrated between fac-
tors that contribute to a patient’s general belief or confi-
dence in a successful recovery and the actual outcome from
surgery (Table 2). Thomeé et al. [54] found that perceived
self-efficacy at completing knee-related tasks in the future
(K-SES-future) was predictive of an acceptable outcome
according to KOOS score, Tegner activity score, or hop
index score. Similar associations were reported by Gobbi
et al. [23] and Langford et al. [33] between measures of
perceived ability and benefit of returning to sport (psych-
ovitality and ACL-RSI scores, respectively) and actual
return to sport at 12-month follow-up. Finally, Swirtun and
Renström [52] found that patients with low pessimism
scores (high optimism) had higher KOOS scores at 5-year
follow-up (Spearman’s rho = -0.36, p \ 0.05).
Self-efficacy in general was also found to affect reha-
bilitation-specific outcome measures (Table 2). Scherzer
et al. [47] found that patients who utilized goal setting or
positive self-talk had had greater rates of home exercise
completion and higher perceived effort during rehabilita-
tion. Brewer et al. [8] found that patients with higher self-
motivation (SMI) were more compliant with home exercise
programs (r = 0.48, p \ 0.001) and had greater effort
during rehabilitation (SIRAS) (r = 0.26, p \ 0.05). A
follow-up cohort study by the same research group [7]
found that the strength of this relationship appears to be age
dependent, with self-motivation being a stronger predictor
of home exercise completion in older patients
(beta = 0.25, p \ 0.05).
Stress, health, and the buffering hypothesis of social
support
There was some evidence to support an association
between stress, social support, and knee surgery outcomes
(Table 2). Specifically, Langford et al. [33] found a trend
towards significance for differences in ERAIQ scores
among athletes who returned to sport at 12 months and
non-returners after adjustment for assessment time point
(p = 0.08, two-factor repeated-measures ANOVA).
Brewer et al. [8] found that higher levels of stress (BSI)
were associated with increased knee laxity, and athletic
identity (AIMS) was associated with decreased knee laxity;
social support (SSI) was positively associated with home
exercise completion (r = 0.22, p \ 0.05). Brewer et al. [7]
demonstrated that as age increases, the relationship
between athletic identity and knee outcomes becomes less
significant, and social support becomes more significant.
Discussion
The most important finding of this systematic review is that
several psychological factors have been consistently dem-
onstrated to be predictive of postoperative outcomes fol-
lowing ACL reconstruction. Sports-related knee surgery
requires a substantial rehabilitative effort on the part of the
patient to achieve a satisfactory outcome. Additionally,
patients must be ready and willing to overcome the fear of
re-injury to return to their original level of activity and

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sports participation. This relationship between patient
psychological traits and postoperative outcomes may par-
tially explain why a subset of patients fail to return to sport
despite adequate surgical restoration of knee function.
There is a consistent relationship between patients’ self-
confidence, optimism, and motivation to recover from
injury and the actual outcome of knee surgery [8, 23, 52,
54]. These factors likely contribute to a patient’s psycho-
logical ‘‘readiness’’ for knee surgery and the subsequent
rehabilitation process. This concept is supported by Ban-
dura’s theory of self-efficacy, which describes the rela-
tionship between intrinsic levels of perceived self-efficacy
(confidence in the ability to complete a task) and actual
behaviour (follow-through) [6]. The majority of studies in
this review lend support to our proposed theoretical
framework of self-efficacy in the context of ACL injury,
surgery, and rehabilitation (Fig. 2), as their measures self-
motivation, self-efficacy, and optimism were associated
with future knee pain, function, and return to sport [7, 8,
23, 33, 47, 54]. Because global measures related to self-
efficacy such as intrinsic optimism [52] and intrinsic self-
motivation [8] are considered to be stable (unchanging
within a year) personality traits, a pre-operative assessment
of these factors to gauge a patient’s psychological ‘‘readi-
ness’’ for sports-related knee surgery has the potential to
help guide individualized treatment recommendations.
The relationship between stress, social support (either
general or in relation to athletic identity), and knee surgery
outcomes is not surprising, as these factors also have an
effect on compliance with medical treatment, overall
quality of life, and general health status [20, 22, 43]. In
particular, levels of stress and perceived social support
appear to affect objective outcomes such as rates of return
to sport in addition to subjective outcomes such as self-
reported pain severity [33, 46]. An interesting age-specific
relationship in which pre-operative activity levels more
positively affect knee surgery outcomes in younger athletes
was identified by several studies in this review. The posi-
tive association between activity levels and outcomes may
be partially due to increased athletic self-identity, which
Brewer et al. [7] postulate is a source of positive social
support in younger individuals (\30 years age). Younger
athletes may derive greater perceived social support from
sports participation than older adults; conversely, surgery
outcomes for older adults (30–40 years) were less strongly
associated with athletic self-identity and more strongly
associated with a general social support index SSI [7].
Investigators should be cognizant of the potential modify-
ing effect of age on these factors when interpreting sports-
related surgical outcomes in a population containing mul-
tiple age groups. Additionally, clinicians and physical
therapists should be aware that younger patients in partic-
ular may be negatively affected by loss of sports
participation and a team environment as a source of social
support. An appropriate way to counterbalance this loss of
social support would be to encourage use of positive cop-
ing strategies such as positive self-talk and goal setting as
described by Scherzer et al. [47] Finally, though stress is
responsive to treatment, routine screening of patients
without any prior indication of either condition may lead to
a high rate of false positives and an unnecessary number of
referrals to mental health professionals. Therefore, addi-
tional research is needed to determine the strength of
relationship between stress and surgical outcomes to more
appropriately assess the risk versus benefit of mental health
screening in a sports medicine setting.
The fear-avoidance model has an important role in
patient behaviour following knee surgery, as kinesiophobia
(negative response towards pain) and pain catastrophizing
(active avoidance of activities out of fear of recurrent pain
and injury) are two psychological factors that are strongly
correlated with lack of return to sport [2, 4, 32, 34, 56].
However, the current review is unable to characterize the
ability of pre-operative screening of patients for heightened
pain catastrophizing and kinesiophobia to predict levels of
these factors after knee rehabilitation. Likely, the negative
findings reported by Chmielewski et al. [11] are largely due
to an inadequate follow-up period, as the range of activities
allowed at 12 weeks postsurgery is far different from full
clearance of sports activities after rehabilitation comple-
tion. Further research with adequate follow-up is indicated
to determine the prognostic role, if any, that a baseline
assessment of pain perceptions or fear of recurrent injury
has on knee surgery outcomes.
The limitations of this review are primarily related to the
quality and design of the included studies. Our review
included prospective studies only, and the quality of studies
included in our review as assessed by the modified Cole-
man score (mean 62.9/90) is comparable to other recent
systematic reviews on sports medicine topics by Mithoefer
et al. [42] (mean 58/100), Cowan et al. [15] (mean 59/100)
and Harris et al. [27] (mean 54/100). However, the major
limitation of our review is that the relationship between
psychological factors and knee surgery outcomes is likely
understated. Two common shortcomings of the included
studies were a small sample size and short follow-up per-
iod, both of which lead to a decreased ability to detect
clinically significant relationships between baseline psy-
chological factors and knee surgery outcomes. Negative
findings were reported for a primary or secondary study
aim in at least 3 of 8 studies, but only one study reported a
power analysis or reasons why a sample size could not be
estimated a priori [11, 33, 52]. Additionally, inadequate
follow-up may minimize the observed effect of psycho-
logical factors on outcomes due to incomplete improve-
ment in knee symptoms and function in many patients at
123

that time point. Finally, use of differing outcome measures
(return to sport, symptom scales, physiological measures,
and measures of compliance) and ceiling effects of symp-
tom scales can both increase false negative error rates.
Conclusion
In conclusion, patient psychological factors are predictive
of ACL reconstruction outcomes. Self-confidence, opti-
mism, and self-motivation are predictive of outcomes,
which is consistent with the theory of self-efficacy.
Stress, social support, and athletic self-identity are pre-
dictive of outcomes, which is consistent with the global
relationship between stress, health, and the buffering
hypothesis of social support. Additional research is nee-
ded to determine the potential role of psychological
screening as a pre-operative predictive tool for knee
surgery outcomes or alternatively as an opportunity for
risk factor intervention.
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